Symptoms Questionnaire

Symptoms Questionnaire

Symptoms Questionnaire

Symptoms Questionnaire

HAVE YOU OR ANYONE ELSE NOTED THE FOLLOWING:

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Headaches


Double Vision​​​​​​​


Words moving/swimming on a page


Eyes Tired/Sore


Dizziness/motion sickness


Frustrated with school


Bothered by light


Frequent Blinking


Closing/Covering one eye or squints​​​​​​​


Difficulty seeing distant objects


Holds work close or head close to work


Avoids reading or other close work


Tilts head when reading


Tilts head when writing​​​​​​​


Confuses or Reverses letters/words/numbers


Skips, rereads, omits words, loses place​​​​​​​


Vocalizes when reading


Reads slowly​​​​​​​


Uses finger or marker when reading


Poor reading comprehension​​​​​​​


Comprehension decreases over time


Writes/Prints poorly


Eyes tire quickly when reading


Homework takes too long


Frequent erasures


Difficulty copying from board


Difficulty with memory


Remembers better what hears than sees


Responds better orally than written


Performing below potential


Dislikes/avoids near tasks


Short attention span/easily distracted​​​​​​​


Poor large motor coordination


Poor fine motor coordination


Avoids/dislikes Sports


Difficulty hitting a ball


Eye strain/blurry vision while reading/working


Often appears clumsy

Your Score:
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